Follow-up Angiographic Studies Research Articles

Stenting for Stenoses of the Proximal Vertebral Artery

We report our initial experience of stenting for symptomatic stenoses of the proximal vertebral artery. A total of 25 lesions affecting the proximal vertebral artery were treated by PTA with stent in 23 patients. The lesions involved the vertebral artery ostium in 20 lesions and the nonostial VI portion in five lesions. The mean stenosis rate of those lesions was 81% pre-stenting and was reduced to 4% post-stenting. There were two transient neurological complications: hemiparesis in one patient and visual acuity disturbance in another. Angiographic followup studies more than three months after treatment demonstrated restenosis in three patients. One of these patients was symptomatic. These restenoses were successfully treated by PTA. Our initial results demonstrated that stenting is a feasible and safe method of treating stenosis of the proximal vertebral artery.

Endovascular treatment of multiple intracranial aneurysms by using Guglielmi detachable coils.

The purpose of this paper is to present the authors' experience with Guglielmi detachable coil (GDC) embolization of multiple intracranial aneurysms and to evaluate the results of this therapy in single-stage procedures. Clinical and angiographic evaluations were performed in 38 consecutive patients with multiple intracranial aneurysms treated by GDC embolization between March 1990 and October 1997. Twenty-nine patients presented with subarachnoid hemorrhage (SAH), four with mass effect, and five were asymptomatic. These 38 patients harbored 101 aneurysms, 79 of which were treated with GDCs, 14 by surgical clipping, and eight were left untreated. Of the GDC-treated lesions, a complete endovascular occlusion was achieved in 55 aneurysms (70%), and 24 (30%) presented neck remnants. Twenty-five patients (66%) underwent GDC embolization of more than one aneurysm in the first session. Eighteen (86%) of 21 patients with acute SAH underwent treatment for all aneurysms within 3 days after admission (15 of 21 in one session). Follow-up angiographic studies in 30 patients demonstrated an unchanged or improved result in 94% of the aneurysms (59 lesions) and coil compaction in 6% (four lesions). The overall clinical outcome was excellent in 34 patients (89%), good in one (3%), fair in one (3%), and death in two (5%). Endovascular treatment of multiple intracranial aneurysms, regardless of their location, with GDCs was performed safely in one session, even during the acute phase of SAH. Treatment of all aneurysms in one session protected the patient from rebleeding and eliminated the risk of mistakenly treating only the unruptured aneurysms.

Immediate and follow-up findings after stent treatment for severe coarctation of aorta

Experimental studies have shown that stents implanted at the aorta become incorporated within the aortic wall and can be further expanded in growing animals. Few clinical studies have shown that the stent repair of severe coarctation of aorta provides excellent initial results, and little is known on the follow-up of these patients. We assessed the immediate and follow-up results obtained in a series of 48 patients (mean age 14 ± 12 years) with severe coarctation of the aorta who were treated by Palmaz stent implantation; 30 of them (63%) underwent angiographic follow-up studies at a mean of 25 ± 11 months after treatment. Quantitative serial analysis of the aortogram (baseline, after treatment, and at follow-up) was performed. Significant relief (mean residual gradient 3 ± 4 mm Hg) was always obtained after stent implantation. The isthmus, when hypoplastic (60%), was always expanded with the stent. One associated aneurysm became occluded after the implant. Complications included aortic disruption, stent migration, and decreased or absent femoral pulses. At angiographic follow-up, the stent remained always in place, without recoil. In 22 patients (73%), there were no detectable neointimal proliferation at late angiogram; however, 8 patients (27%) had some degree of intimal thickening (1 to 5 mm), causing mild restenosis in 3 patients treated at early age, and nonsignificant lumen reduction in 5. The serial aortogram analysis revealed a minor but significant increase in nonstented aortic diameters that seemed related to the normal growth of children. No need for stent reexpansion was observed at 2-year follow-up (mean). Two patients (7%) developed late small aneurysm formation at the stented wall; both were occluded by the insertion of coils through the stent orifices. We conclude that stent treatment for severe coarctation of aorta provides excellent immediate and long-term results in young adults and children. However, at early age, restenosis by intimal growth may develop.

Optimal coronary balloon angioplasty with provisional stenting versus primary stent (OCBAS): Immediate and long-term follow-up results

Objective. This study sought to compare two strategies of revascularization in patients obtaining a good immediate angiographic result after percutaneous transluminal coronary angioplasty (PTCA): elective stenting versus optimal PTCA. A good immediate angiographic result with provisional stenting was considered to occur only if early loss in minimal luminal diameter (MLD) was documented at 30 min post-PTCA angiography.Background. Coronary stenting reduces restenosis in lesions exhibiting early deterioration (>0.3 mm) in MLD within the first 24 hours (early loss) after successful PTCA. Lesions with no early loss after PTCA have a low restenosis rate.Methods. To compare angiographic restenosis and target vessel revascularization (TVR) of lesions treated with coronary stenting versus those treated with optimal PTCA, 116 patients were randomized to stent (n = 57) or to optimal PTCA (n = 59). After randomization in the PTCA group, 13.5% of the patients crossed over to stent due to early loss (provisional stenting).Results. Baseline demographic and angiographic characteristics were similar in both groups of patients. At 7.6 months, 96.6% of the entire population had a follow-up angiographic study: 98.2% in the stent and 94.9% in the PTCA group. Immediate and follow-up angiographic data showed that acute gain was significantly higher in the stent than in the PTCA group (1.95 vs. 1.5 mm; p < 0.03). However, late loss was significantly higher in the stent than the PTCA group (0.63 ± 0.59 vs. 0.26 ± 0.44, respectively; p = 0.01). Hence, net gain with both techniques was similar (1.32 ± 0.3 vs. 1.24 ± 0.29 mm for the stent and the PTCA groups, respectively; p = NS). Angiographic restenosis rate at follow-up (19.2% in stent vs. 16.4% in PTCA; p = NS) and TVR (17.5% in stent vs. 13.5% in PTCA; p = NS) were similar. Furthermore, event-free survival was 80.8% in the stent versus 83.1% in the PTCA group (p = NS). Overall costs (hospital and follow-up) were US $591,740 in the stent versus US $398,480 in the PTCA group (p < 0.02).Conclusions. The strategy of PTCA with delay angiogram and provisional stent if early loss occurs had similar restenosis rate and TVR, but lower cost than primary stenting after PTCA.

Abstracts of Literature

Abstracts of Literature

How to standardize vasomotor tone in serial studies based on quantitation of coronary dimensions?

In patients with coronary artery disease including those after coronary bypass graft operation and heart transplantation intervention studies based on serial quantitative coronary angiography, in part combined with intravascular ultrasound, are of increasing relevance. Since vasomotor tone of epicardial coronary arteries is influenced by a variety of factors, angiographic follow-up studies require standardization of coronary tone by induction of maximal dilation. We reviewed the effects of the most potent coronary vasodilatory drug groups, calcium antagonists and nitrocompounds, on coronary diameters. Intravenous or intracoronary injections of verapamil, diltiazem, nifedipine, nicardipine, and nisoldipine can cause profound coronary dilation which has been shown to be maximal with verapamil and nisoldipine. Shortcomings of calcium antagonists include short or unknown duration of action after bolus administration, severe drop in blood pressure, and lack of commercial availability of solutions for injection of many substances. Isosorbide dinitrate induces profound coronary dilation; however, after sublingual administration marked blood pressure decrease can occur, and the duration of action and ideal dose of intracoronary isosorbide dinitrate has not been investigated yet. Injections of molsidomine and its active metabolite, SIN-1, cause longlasting, reproducible, maximal coronary dilation, although only after a waiting period of at least 10 minutes; unfortunately, SIN-1 is only commercially available in France. Nitroglycerin induces reproducible maximal coronary dilation and is easy to administer sublingually or as intracoronary bolus injection with rapid onset of action and no major side effects. The short duration of action may require repeated administrations. To date, repeated intracoronary bolus injections of 0.1 mg nitroglycerin every 10 minutes seem to be the optimal known regimen for standardization of coronary vasomotor tone in serial angiographic studies. Further investigations in this field with old and new vasodilatory drugs are recommendable.

Intracranial aneurysm: anatomic factors that predict the usefulness of intraoperative angiography.

To correlate the size and location of intracranial aneurysm with the need to reposition the aneurysm clip after intraoperative angiography. In 199 consecutive patients with 234 clipped intracranial aneurysms, 273 intraoperative angiographic studies were retrospectively reviewed. Aneurysm size and location, determined with preoperative angiographic and surgical reports, were correlated with the frequency of clip repositioning because of parent- or branch-vessel compromise or unexpected residual aneurysm. Findings from intraoperative angiograms resulted in clip repositioning in 46 of 273 (16.8%) studies. Clip repositioning was statistically significantly less frequent with aneurysms of the posterior communicating (three of 52 [5.7%] studies) and anterior choroidal (none of 12 studies) arteries. High rates of clip repositioning were found in aneurysms of the superior hypophyseal artery (seven of 18 [38.9%] studies), superior cerebellar artery (three of five [60.0%] studies), and bifurcation of the internal carotid artery (three of nine [33.3%] aneurysms). In 98 conventional follow-up angiographic studies, seven (7%) false-negative cases with unsuspected aneurysm neck remnant were found. The rate of clip repositioning in aneurysms of the posterior communicating or anterior choroidal arteries was less than that at other locations (P < .05). Intraoperative angiography may not be necessary when aneurysms are at these two locations.

Moyamoya disease in adults: characteristics of clinical presentation and outcome after encephalo-duro-arterio-synangiosis

To determine the clinical characteristics and the effectiveness of encephalo-duro-arterio-synangiosis (EDAS) in adulthood-onset Moyamoya disease (MMD), the authors retrospectively reviewed 26 patients suffering from MMD who were admitted to Seoul National University Hospital between 1987 and 1995. When they showed major symptoms, all were more than 16 years-old. The most common presenting symptom was intracranial hemorrhage (ICrH), found in 12 patients or 46% of the total; the second was infarction and transient ischemic attack, each found in seven or 27% of them. Only one patient was found to have seizures, which were associated with a cerebral infarction. The Suzuki angiographic stage 3 and less than stage 3 accounted for 73% of all 52 hemispheres. A total of 15 patients underwent single photon emission computed tomography (SPECT) preoperatively. When the derangement of cerebral perfusion was estimated with four SPECT grades (SG), 70% of their hemispheres revealed normal (SG1) or localized decreased-perfusion (SG2). The other 30% had extensive decreased-perfusion or localized perfusion defects (SG3). There was no case who had extensive perfusion defects (SG4). A total of 17 patients underwent EDAS operations (EDAS group) and nine did not undergo any operation (no-op group). The EDAS group had significantly better clinical outcomes than the no-op group after a 12-month median follow-up period (P<0.05). The angiographic and SPECT follow-up studies comprised six and seven cases, respectively. There was also satisfactory angiographic revascularization in all follow-up cases and improvement in cerebral perfusion at SPECT follow-up in six of seven cases. It is concluded that the involvement of posterior circulation of MMD is not frequent and cerebral perfusion is preserved in adulthood-onset MMD patients. These findings may explain the reason why hemorrhages are frequent and the late onset of symptoms in adulthood-onset MMD. Surgical treatment with EDAS seems to be effective in adulthood-onset MMD in terms of clinical improvement.

Angio-RM post-trattamento delle malformazioni vascolari spinali

Twenty-five patients with spinal vascular malformations demonstrated by spinal arteriography (21 dural arteriovenous fistulas, 2 perimedullary arteriovenous fistulas and 2 intramedullary arteriovenous malformations) underwent MR imaging and contrast enhanced phase-contrast MR angiography before and after endovascular (n?18) or surgical (n=7) treatment. In 3 patients with dural arteriovenous fistula treated with glue embolization, early post-treatment MR angiography showed persistence of flow in the perimedullary vessels. The patency of the fistula was confirmed by spinal arteriography or surgery in all three patients. In two other patients with dural arteriovenous fistulas treated with glue injection, delayed MR angiography showed flow in perimedullary vessels which was not observable in early post-treatment MR angiography controls. Reopening (“recurrence”) of the fistula was confirmed by arteriography in one patient. In the remaining 16 patients with dural arteriovenous fistula, post-treatment MR angiography showed disappearance of flow in the perimedullary vessels consistent with obliteration of the fistula. This finding was associated with persistent intramedullary signal changes and contrast enhancement in 13 patients and perimedullary contrast enhancing vessels in 6 patients. Arteriography in one of the latter patients showed exclusion of the fistula confirming the result of the posttreatment MR angiography study. In the 4 patients with high flow spinal vascular malformations, all treated with endovascular approach, early post-treatment MR angiography showed reduction or disappearance of flow in the abnormal vessels. This remained unchanged in two patients, where as increased flow in the same vessels was demonstrated by further follow-up MR angiography studies in two patients. Phase contrast MR angiography is a useful complement to MR imaging in the post-treatment evaluation of spinal vascular malformations. An early post-treatment MR-angiography control is recommended as it enables prompt identification of treatment failures and may constitute a reference term for lesion monitoring over time.

Initial experience with the Cordis stent: analysis of serial angiographic follow-up.

To evaluate the efficacy of the more flexible Cordis stent, a prospective angiographic follow-up study was performed. Implantation of the Cordis stent was attempted in 99 consecutive patients with 103 native coronary lesions from January 1994 to July 1995. Clinical success, defined as final diameter stenosis of < 50% without death, bypass surgery, or Q-wave myocardial infarction, was achieved in 88% of the patients. There were no in-hospital deaths. In-hospital subacute stent occlusion occurred in only one case. Follow-up angiograms were obtained in 86 (95%) eligible lesions. The minimal luminal diameter improved from 1.03 +/- 0.31 to 2.82 +/- 0.31 mm, but started to decrease at 1 mon (2.57 +/- 0.24 mm), and continued to decrease throughout the 6 mon (2.00 +/- 0.61 mm), the biggest reduction being between 1 and 3 mon (-0.57 +/- 0.50 mm). Angiographic restenosis (stenosis > or = 50%) occurred in 23% of the lesions; a revascularization procedure of the target lesion was required in 12% of the patients. Multivariate analysis identified age, diabetes mellitus, and preprocedural reference diameter to be predictors of angiographic restenosis. In conclusion, the Cordis stent can be implanted successfully with a low complication rate and a clinical outcome at least comparable to other stent studies.

Endovascular treatment of cerebral aneurysms following incomplete clipping

The authors report their experience using electrolytically detachable coils for the treatment of residual cerebral aneurysms following incomplete surgical clipping. Eight patients were treated for six anterior and two posterior circulation aneurysm remnants. All patients were referred for endovascular treatment by experienced cerebrovascular neurosurgeons at the authors' institution. Patients underwent follow-up angiography immediately after endovascular treatment. In seven of the eight patients, additional follow-up angiographic studies were obtained at periods ranging from 7 weeks to 2 years posttreatment. The latest follow-up angiograms demonstrated that six of the eight aneurysm remnants were 100% occluded, with near-complete occlusion of the other two aneurysm remnants. There was no permanent neurological or non-neurological morbidity or mortality associated with the treatment. There was no incidence of aneurysm hemorrhage during or after treatment. Endovascular treatment of cerebral aneurysm remnants following prior surgical clipping can be accomplished with acceptable morbidity and mortality rates. Endovascular coil occlusion can play an important adjunctive role in the treatment of those aneurysms that have been incompletely obliterated by surgical clipping.

Rest-redistribution Tl-201 SPECT to predict functional recovery: Results from an angiographic follow-up study

Rest-redistribution Tl-201 SPECT to predict functional recovery: Results from an angiographic follow-up study

Angiographic 5-year follow-up study of right gastroepiploic artery grafts

The right gastroepiploic artery (RGEA) has been used from 1987 in coronary artery bypass grafting in several clinical studies. However, the published 1- to 5-year patency rates have been dependent on the selection of patients for angiography. In our study, the RGEA was used from March 1987 to May 1990 for coronary artery bypass grafting in 31 consecutive patients, 25 male and 6 female. All but 1 patient had triple-vessel disease, and the mean number of distal anastomoses was 3.9 (range, 2 to 5). Internal thoracic artery grafts were used concomitantly in all patients. One early and two late deaths occurred. All but 1 of the 28 surviving patients underwent clinical and angiographic follow-up examinations 3 months and 5 years after the operation. The 5-year patency of RGEA grafts was 82.1%, with a 95% confidence interval of 63.1% to 93.9%. In 4 of the 5 nonvisualized cases, the recipient coronary artery showed proximal stenosis of up to 70%, allowing substantial competitive flow. The 5-year patency of the RGEA graft was near that of the left internal thoracic artery, at 90.3%, and the right internal thoracic artery, at 94.4%; and superior to the 66.7% patency of venous grafts. At 5-year follow-up, angiography of RGEA grafts showed good function and a smooth lumen, especially if the proximal stenosis was more than 70%.

Growth potential in the new aortic arch after non-end-to-end repair of aortic arch interruption in infancy

Complete repair of infants with interrupted arch and ventricular septal defect through a midline incision has been the preferred method for more than 20 years. End-to-end anastomosis can result in restenosis if there is excess tension. Two methods of reducing this tension have been described, and the subsequent growth of the new aortic arch is demonstrated. In 2 infants (5 and 9 months old) the duct was used to create a new aortic arch. In 3 other younger infants the left carotid artery was divided, turned down, and anastomosed to the descending aorta to form the new arch. These operations were performed through the midline at the same time as the ventricular septal defect was closed. All 5 patients are well now 8 to 19 years postoperatively. One patient required reoperation for stenosis at the anastomotic site, but all have subsequently shown good growth on follow-up angiographic and magnetic resonance imaging studies. Although end-to-end repair is best, these alternative methods have shown very satisfactory aortic growth into adult life.

Dessein Explicatif, Milan 22.3.96

An attempt to retrieve gently the coil also failed and the coil prematurely detached. For maintaining the patency of the arterial lumen and to reduce the embolic risk, a second stent was used to pin the free coil loops. The rescue stent was positioned within the coil loops and its deployment allowed a circumferential expansion of some loops around the stent perimeter while other loops were flattened against the wall of the artery. The parent artery remained patent at one-year follow-up angiographic study. No clinical complications were observed.

Prognostic importance of intimal thickness as measured by intracoronary ultrasound after cardiac transplantation.

Although intracoronary ultrasound (ICUS) has been validated for the early detection of transplant coronary artery disease (TxCAD), the prognostic importance of findings detected by this new imaging technique is unknown. This study examined the relation of clinical outcome in 145 heart transplant recipients (mean age, 45.1 +/- 11.1 years) with the amount of intimal thickness measured by ICUS during routine annual coronary angiography 1 to 10 years (mean, 3.1 +/- 2.2 years) after transplantation. From published autopsy data, a mean intimal thickness of > 0.3 mm was considered significant. During a mean follow-up time of 48.2 +/- 10.2 months, 23 deaths (12 cardiac) occurred, and 6 patients required retransplantation. Angiographic TxCAD developed in 22 of 125 patients (17.6%) in the subgroup with normal angiograms at the time of ICUS and a follow-up annual angiographic study. In the total population and the subgroup, mean intimal thicknesses of > 0.3 and < or = 0.3 mm, respectively, were associated with significantly inferior 4-year actuarial overall survival (73% versus 96%, P = .005; 72% versus 92%, P = .05), cardiac survival (79% versus 96%, P = .005; 80% versus 98%, P = .04), and freedom from cardiac death and retransplantation (74% versus 98%, P < .0001; 70% versus 96%, P = .001). In addition, ICUS predicted freedom from development of subsequent angiographic TxCAD in the subgroup that was initially normal (26% versus 72%, P = .02). A mean intimal thickness by ICUS of > 0.3 mm was associated with inferior clinical outcome regardless of the presence of angiographic TxCAD and predicted the development of subsequent angiographic TxCAD. Despite significantly longer duration after transplantation, higher rejection incidence, and lower average daily cyclosporine dose, none of these covariates were independent risk factors for outcome. These findings confirm the prognostic importance of mean intimal thickening of > 0.3 mm in heart transplant recipients and suggest that these patients should be candidates for early interventional strategies.

Ability of the no-reflow phenomenon during an acute myocardial infarction to predict left ventricular dysfunction at one-month follow-up

Despite angiographically successful opening of an infarct-related vessel within a 6-hour time frame, some patients do not recover left ventricular regional wall function in the infarct zone after an acute myocardial infarction (AMI). Recent evidence suggests that this finding is due to the no-reflow phenomenon, or failure to recover tissue perfusion despite patent epicardial arteries. We performed myocardial contrast echocardiography to assess tissue perfusion before and after opening of an infarct-related artery. Coronary angiograms, regional wall motion scoring, and myocardial contrast enhancement were graded by 3 observers. Of 24 patients with AMI, 7 (29%) failed to recover tissue perfusion in ≥1 region of myocardium. Of 106 regions subtended by the infarct-related artery, 16 (15%), 43 (41%), and 47 (44%) regions had no-reflow, partial, or normal flow, respectively, after arterial patency was established. There was a spectrum of reperfusion patterns ranging from no-reflow to normal perfusion. Onemonth follow-up angiographic and myocardial contrast echocardiographic studies were performed in 12 of the 24 patients. At 1 month, all segments of myocardium that had immediate normal perfusion had regained normal wall motion. In contrast, 17 segments that had partial or no-reflow were identified. Of these 17, 3 regained normal function, 10 segments were hypokinetic, and 4 segments were akinetic. We conclude that myocardial contrast echocardiography can be used to identify the no-reflow phenomenon in up to 29% of patients with AMI. Additionally, we found that the immediatere-flow pattern can predict degree of left ventricular dysfunction at 1-month follow-up.

Follow-up patency of side branches covered by intracoronary Palmaz-Schatz stent

To assess the risk of late side branch occlusion after Palmaz-Schatz stent deployment, we analyzed the angiographic evolution of 62 patients treated by successful stent implantation who had a total of 85 side branches starting from the stented segment. Side branches were considered minor ( n = 39) when the diameter was <1 mm and intermediate ( n = 46) when the vessel had ≥1 mm diameter. One angiographic follow-up study was available in all patients at 8 ± 5 months. Eight minor branches presented some degree of stenosis at origin before stent deployment (4 totally occluded). After stent deployment, 32 (82%) of 39 remained unchanged and 3 became occluded. Late progression at origin occurred in 4 of 34 (3 occluded). Before stent deployment, 48% of the intermediate branches had some compromise degree at their starting point (1 totally occluded). Eight of 45 intermediate branches became occluded after stent implantation. Late progression at origin happened in 5 of 32 branches (2 occluded). Some degree of follow-up stenosis regression at the origin was observed in 22 (26%) of 85 arteries. Neither clinical nor angiographic factors could be identified as predictors of late side branch occlusion or stenosis progression at its origin. Later occlusion or progression at origin of a side branch covered by a Palmaz-Schatz stent seems to be an uncommon occurrence (7% and 12% respectively) that cannot be predicted by angiographic or clinical factors. On the contrary, regression at follow-up of a side branch—origin stenosis can also come about.

951-70 Absence of Bleeding and Subacute Occlusion After Palmaz-Schatz Coronary Stenting Using a New Antithrombotic Regimen

Subacute thrombotic occlusion and bleeding complications related to antithrombotic therapy are the major limitations of elective coronary stenting. The effectiveness of a new antithrombotic regimen without full early anticoagulation to prevent these complications has been evaluated in 52 consecutive pts (62 ± 11 years, 82% male) who underwent elective Palmaz-Schatz stenting in 58 lesions. Four lesions were restenotic and 3 lesions were located in venous graft. The mean reference diameter was 3.3 ± 0.6 mm, with a mean diameter stenosis of 71 ± 9%. Intravenous heparin was given only during the procedure. After stenting, the pts were treated with aspirin, dipyridamole, dextran, warfarin and subcutaneous low molecular weight heparin (LMWH) [enoxaparine, 40 mg/day]. LMWH was started 6 h after stenting and stopped when an INR of 2–3 was achieved, The aPTI and the INR were determined daily before discharge. In all pts, serial quantitative angiographic follow-up (FU) study was performed at 24 hours, 30 days and 6 months after stenting. Optimal angiographic stent result was achieved in 98% of the lesions, and minimal lumen diameter (MLD) increased from 1.2 ± 0.4 to 3.6 ± 0.5 mm (p &lt; 0.001). The aPTI remained normal (mean: 32 ± 5.6 sec, range: 24 to 48 sec) during LMWH administration; and an INR &gt;2 was achieved 3 days after intervention in 94% of stented pts. Neither an event (myocardial infarction. coronary surgery or death) nor major bleeding occurred during the first month. At 24 hand 1 month angiographic FU, all stented lesions remained patent, with no significant changes in MLD. At 6 months FU, all stented arteries remained patent, MLD decreased significantly to 2.5 ± 0.8 mm (p &lt; 0.001), and a restenosis rate of 23% (95% CI: 13–36%) of stented lesions (stenosis ≥50% criteria) was observed. These data suggest that, after elective stenting with optimal angiographic result, the initial combination of LMWH (with no significant effect on aPTT) plus anti platelet therapy, followed by anticoagulation with coumadin, prevent subacute occlusion and bleeding complications, without detrimental effect on previous reported restenosis rate.

Stereotactic multiple arc radiotherapy. I. Vascular malformations of the brain: an analysis of the first 108 patients.

Between March 1989 and December 1993, 101 patients with inoperable arteriovenous malformations (AVMs) and seven patients with inoperable angiographically occult malformations (AOVMs) have been treated with stereotactic multiple arc radiotherapy (SMART). All patients (excluding one patient with a brain stem AOVM) were treated with a uniform dose of 1750 cGy prescribed to the 90% isodose. Fifty-two patients with AVMs have had follow-up angiographic studies performed 11-42 months after SMART. The complete angiographic obliteration rates were 75-77% for AVMs < 10 cm3 and 40-75% for AVMs > 10 cm3, when studied 18-30 months after SMART. Four patients re-bled prior to complete obliteration representing an actuarial 2-year incidence of re-bleeding of 5.1%. Seven patients developed a new neurological deficit after SMART after a median latent interval of 17 months (range 6-32). The actuarial 2-year incidence of neurological complications was 1.8% for lesions < 10 cm3. The actuarial 2-year incidence of neurological complications was 16% for lesions > 10 cm3 (10.5% for persisting deficit). Of seven patients with AOVM six have shown a reduction in size and degree of contrast enhancement, but in no patient has there been complete resolution shown by CT. Five patients with AOVMs developed symptomatic neurological deterioration at a median of 6 months after SMART (range 5-9). When viewed in the context of the natural history of conservatively managed inoperable AVMs, this series has demonstrated that our highly specialized irradiation technique is a safe and effective treatment for many patients.